ORIGINAL ARTICLE
Laparoscopic versus open bowel resection for Crohn’s disease 1
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Jeanine Tabet MD PhD , Dennis Hong MD , Cei-Whan Kim MD , Jason Wong BSc MD FRCSC , 2 1 Robert Goodacre MB BS MRCPUK FRCPSC , Mehran Anvari MB BS PhD FRCSC FACS
J Tabet, D Hong, C-W Kim, J Wong, R Goodacre, M Anvari. Laparoscopic versus open bowel resection for Crohn’s disease. Can J Gastroenterol 2001;15(4):237-242. BACKGROUND: Laparoscopic bowel resection is an alternative to open surgery for patients with Crohn’s disease requiring surgical resection. The present report describes a seven-year experience with the laparoscopic treatment of Crohn’s disease compared with the open technique in a tertiary Canadian centre. PATIENTS AND METHODS: A retrospective analysis of 61 consecutive patients undergoing elective resection for Crohn’s disease was carried out between October 1992 and June 1999. This analysis included 32 laparoscopic resections (mean age 33 years) and 29 open resections (mean age 42 years). Patient demographics were compared, as well as short and long term outcomes after surgery (mean follow-up 39 months). RESULTS: Patients in the laparoscopic group were younger and had fewer previous bowel surgeries than patients who had open resections. Indications for surgery and operative times were similar between the groups. Patients who underwent laparoscopic resections required fewer doses of narcotic analgesics. The resumption of bowel function after surgery, and tolerance of a clear liquid and solid diet was quicker in the laparoscopic group. Patients who underwent laparoscopic resections had significantly shorter hospital stays than those who underwent open resections. Fifteen patients (48.4%) in the laparoscopic group experienced recurrence of disease compared with 13 patients (44.8%) in the open group. In both groups, the most common site of recurrence was at the anastomosis. The disease-free inter1
val was the same length for both groups (23.9±17.3 months for the laparoscopic resection patients compared with 23.9±20.2 months for the open resection patients; P=1.00). CONCLUSIONS: Laparoscopic resection for Crohn’s disease can be performed safely and effectively. Quicker resumption of oral feeds, less postoperative pain and earlier discharge from hospital are advantages of the laparoscopic method. No differences in the recurrence rate or the disease-free interval were noted. Key Words: Crohn’s disease; Laparoscopy; Surgical outcome
Résection intestinale laparoscopique versus ouverte dans la maladie de Crohn HISTORIQUE : La résection intestinale laparoscopique est une solution de rechange à la chirurgie ouverte chez les patients atteints de maladie de Crohn chez qui il faut procéder à une résection chirurgicale. Ce rapport décrit une expérience échelonnée sur sept ans sur le traitement laparoscopique de la maladie de Crohn comparativement à une technique ouverte dans un centre de soins tertiaires canadien. PATIENTS ET MÉTHODES : Une analyse rétrospective de 61 patients consécutifs devant subir une résection élective pour maladie de Crohn a été effectuée entre octobre 1992 et juin 1999. Cette analyse incluait 32 résections laparoscopiques (âge moyen, 33 ans) et 29 résections ouvertes (âge moyen, 42 ans). Les caractéristiques démographiques des patients ont été comparées, de même que les résultats à court et à long terme de la chirurgie (suivi moyen, 39 mois).
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Departments of Surgery and Gastroenterology, St Joseph’s Hospital, McMaster University, Hamilton, Ontario Correspondence and reprints: Dr Mehran Anvari, Department of Surgery, St Joseph’s Hospital, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6. Telephone 905-522-2952, fax 905-521-6113, e-mail
[email protected] Received for publication November 10, 1999. Accepted January 18, 2000 Can J Gastroenterol Vol 15 No 4 April 2001
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Tabet et al
RÉSULTATS : Les patients du groupe sous laparoscopie étaient plus jeunes et avaient été opérés moins souvent à l’intestin que les patients qui avaient subi une résection ouverte. Les indications de la chirurgie et la durée des interventions ont été semblables dans les deux groupes. Les patients qui ont subi des résections laparoscopiques ont eu besoin de doses moins nombreuses d’analgésiques de type narcotique. La reprise de la fonction intestinale après la chirurgie et la tolérance d’une alimentation à base de liquide clair et de solides ont été plus rapides dans le groupe ayant subi la laparoscopie. Les patients de ce groupe ont en outre séjourné significativement moins longtemps à l’hôpital que les patients qui ont subi une chirurgie ouverte. Quinze patients (48,4 %) du groupe laparoscopie ont connu une récurrence de la maladie, contre 13
ver the past decade, a number of laparoscopic procedures, including laparoscopic bowel resections, have gained wide acceptance. While the use of laparoscopic surgery for the treatment of colorectal cancer is still controversial, many authors have reported good results when laparoscopic techniques are used in patients with benign colorectal disease, especially in those with Crohn’s disease (1-9); a shorter hospitalization is of benefit to this population of mainly young and employed people. Despite the reported short term benefits of the laparoscopic technique, most Canadian centres do not offer this alternative to patients with Crohn’s disease requiring surgery. This is, in part, due to a lack of adequate long term follow-up to examine the disease-free interval and the long term outcome after laparoscopic surgery. There is also a lack of surgeons with the necessary skills to offer these procedures. Until convincing evidence is accumulated to show the clear benefits of this technique, the current status is unlikely to change significantly. This short and long term outcomes of 61 patients undergoing elective resection for Crohn’s disease by open and laparoscopic techniques in a tertiary centre in Canada are reported.
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PATIENTS AND METHODS Patients: Sixty-one consecutive patients who underwent elective surgery for Crohn’s disease between October 1992 and June 1999 were studied. They were assessed preoperatively by physical examination, contrast radiography, ultrasonography, computed tomography scan (where applicable) and endoscopy. All patients underwent a standard mechanical bowel preparation and received preoperative broad spectrum antibiotics. Patients who underwent surgery for the recurrence of Crohn’s disease were included. Converted cases were included in the laparoscopic group. Surgical technique: All patients underwent either laparoscopic-assisted resections by two surgeons experienced in minimally invasive surgery or open resections by nine surgeons at the authors’ institution. Operative techniques for laparoscopic resections have been described elsewhere (10,11). Bowel mobilization was done laparoscopically through four or five trocars. Bowel resection and anastomosis were performed extracorporeally through a small (4 to 6 cm) muscle splitting incision, except for anterior 238
(44,8 %) dans le groupe sous intervention ouverte. Dans les deux groupes, le site le plus fréquent des récurrences a été l’anastomose. L’intervalle sans maladie a été de la même durée pour les deux groupes (23,9 ± 17,3 mois pour les patients ayant subi la résection laparoscopique, contre 23,9 ± 20,2 mois pour les patients ayant subi la résection ouverte, p = 1,00). CONCLUSIONS : La résection laparoscopique pour la maladie de Crohn peut être effectuée de façon sécuritaire et efficace. La reprise plus rapide de l’alimentation orale, la douleur post-opératoire moins grande et le congé plus hâtif de l’hôpital sont des avantages associés à la méthode laparoscopique. On n’a noté aucune différence quant au taux de récurrence ou quant à l’intervalle sans maladie.
resections, in which anastomosis was done intracorporeally. A stapled anastomosis was performed in all cases. Conversion to the open technique was indicated when the surgeon was unable to fully mobilize the diseased segment laparoscopically and a larger incision was necessary to complete the resection. Postoperative care: Oral intake was initiated by the first postoperative day. Postoperative pain was objectively assessed by evaluation of the total number of days that parenteral and oral narcotic analgesics were needed. Length of hospitalization was defined as the length of postoperative stay. Complications were classified as major (life-threatening) or minor (nonlife-threatening). Perioperative mortality was defined as death occurring within 30 days after the operation. Outcome variables measured: Parameters reviewed included patient characteristics, operative variables, and short term and long term outcomes. Patient characteristics included age, sex, smoking habit, previous surgery, indications for surgery and time from diagnosis of the disease to first surgery. Operative variables included type of resection, operative time, conversion to open surgery and intraoperative complications. Short term outcomes included postoperative complications, time to resumption of oral intake, time to first bowel movement, number of days on analgesics, length of stay and 30-day mortality. Long term outcomes included recurrence rate, disease-free interval and number of re-operations. Recurrence of disease was defined as the recurrence of preoperative symptoms with confirmation by contrast radiography and/or endoscopy with biopsy. Statistical analysis: Continuous variables were compared using Student’s two-tailed t test. Categorical variables were 2 analyzed using Pearson’s χ test or Fisher’s exact test. Results are reported as means (± SD). Significance was considered at P
